Basic Information
Provider Information | |||||||||
NPI: | 1053512590 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILES | ||||||||
FirstName: | LEESA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14 MONTEVALLO ROAD | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 35213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 4TH AVE S | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352332521 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2052635800 | ||||||||
FaxNumber: | 2052635850 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 18552 | AL | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 515-34900 | 01 | AL | PHYSICAL THERAPY PROVIDER | OTHER | 515-34815 | 01 | AL | PHYSICAL THERAPY PROVIDER | OTHER |